1. ANCC Manual and AzNA Update for Approved Providers August 2012
Cyndie Koopsen, RN, BSN, MBA, HNB-BC, RN-BC
AzNA CE Review Coordinator

2. Objectives
At the conclusion of this session, participants will be able to:
Describe key updates and compliance issues related to new 2013 ANCC manual.
Describe the four components of the accreditation conceptual framework
Describe the process for developing activities in adherence with 2013 ANCC accreditation criteria
Compare and contrast requirements and criteria of the manual and the 2013 manual
Identify characteristics of strong documentation using a narrative format
Describe the application and review process for applicant and accredited providers
State annual reporting requirements for Accredited Providers

3. Documents for session Provider Unit Activity Review Form
AzNA Approved Provider Application
AzNA Approved Provider Instructions
Sample Responses
CE Activity Summary
For additional information
for updates
AzNA Today newsletter (bi-monthly)
Arizona Nurse magazine (quarterly)

4. Primary Accreditation framework
Nursing Professional Development Continuing Education
Structural Capacity
Commitment
Accountability
Leadership
Resources
Educational Design Process
Needs Assessment
Planning
Design Principles
Achievement of Objectives
Quality Outcomes
Evaluation Process
Evaluation Participation
Goals for Improvement
Value/Benefit to Nursing Professional Development

5. APPLICATION OVERVIEW Eligibility Requirements—unchanged
Primary Nurse Planner requirements--unchanged
Overall Structure of Self-Study—complete revision
Major criteria...Approved Provider…
Meets eligibility
Activities have merit
Self-study reflects quality in CE process

6. Organizational overview (OO)
Provides context for understanding the organization
Replaces Executive Summary and Self-Assessment
No Mission Statement required
Organizational chart, flow chart, or similar image still required

7. Compliance Attestation statement
Attestation statement is present and is signed and dated.
Appraisers then evaluate the applicant organization in relation to the components of the attestation statement, which may include but are not limited to:
Complaints about the applicant organization as an entity, the quality of educational activities offered (accredited provider) or the quality of activities approved (accredited approver).
The organization’s response to complaints about its products or services from stakeholders or customers.
Congruence between narrative explanations in the self-study documents and evidence found in other documents, on web sites, in verbal descriptions from staff, learners, customers, presenters, etc.
Adherence to laws and regulations such as the Americans with Disabilities Act, Rehabilitation Act, harassment and discrimination laws, and laws and regulations related to copyright, trademarks or intellectual property.

8. Educational design process
New design
Requirements for planning, implementing and evaluating educational activities according to accreditation criteria
ANCC’s definition of eligible CE content:
Generalizable beyond employer setting (“transferrable”)
Beyond basics for the professional registered nurse
Evidence-based/based on best-available evidence
No minimum requirement for contact hours

9. Assessment of learner needs
Variety of methods – no “right way”
Method must be appropriate for your target audience
Identify and validate a gap in knowledge, skills or practice for target audience
Evidence must be included in activity file documentation

10. Nurse planner and one other planner
Key role in all planning
Must adhere to ANCC accreditation criteria
Education expertise/experience—must be documented
Target audience member requirement removed
NP reviews:
Faculty/presenters/authors
Content reviewers
Content experts
Target audience—is it appropriate?
Documentation of biographical data/qualifications for role on committee
Assessment of conflicts of interest
Nurse Planner---another planning committee member must review bio form and validate no NP COI
All individuals having the opportunity to influence content must be evaluated for potential conflicts of interest

11. Conflict of interest Definition Evaluation Resolution and Assessment
Relationships with commercial interest organizations
Include spouse/significant other
Past 12 months
Evaluation
No relationship (of person/spouse now or during past 12 months)
Relationship present (or in past 12 months), not relevant to content, no resolution required (ex. Relationship w/ pharma but content is leadership, so COI relationship not relevant)
Relationship present, relevant to content, resolution required (ex. Relationship w/pharma making asthma drugs but content is on cardiac drugs)
Resolution and Assessment
Remove individual with relationship
Revise role for individual with relationship
Don’t award contact hours
Review content for bias before activity and monitor activity
Review content for bias before activity and evaluate participant feedback

12. Educational design process
Teaching/learning strategies
Methods used to teach
Learner feedback mechanism
Successful completion & criteria for determining with rationale
Method to ensure content integrity and prevention of bias (if financial or in-kind support accepted)
Activity Purpose—learner focused (not provider focused)
Content—based on current available evidence
Evaluation
Short-term
Long-term
Congruent w/purpose of activity (ex. Practice change is not “short-term”)
Category of evaluation—No longer required
Accreditation statement
Certificate of completion
Marketing materials

13. Commercial support vs. sponsorship
Commercial Support: financial or in-kind contribution given by a commercial interest that is used to pay for all or part of an educational activity
Sponsorship: financial or in-kind contribution given by a non-commercial interest organization that is used to pay for all or part of an educational activity
Money for exhibit space is not considered commercial support or sponsorship
The organization providing commercial support or sponsorship may not co-provide the educational activity
Commercial support or sponsorship agreement required

14. Educational design process
Disclosures
Required:
Requirements for successful completion including purpose or objectives (ex. Attend all of activity)
Criteria used to determine successful completion (ex. Complete and submit evaluation form)
Presence or absence of conflicts of interest
If applicable:
Commercial support
Sponsorship
Non-endorsement of products (provider and ANCC)
Expiration date (enduring materials only)
Off label use—no longer required

15. Quality Outcomes
PU’s process for evaluating effectiveness of unit (vs. courses)
PU’s strategic goals for past 12 months
Input from specific stakeholders and why these stakeholders participate in evaluation process
Quality outcome measures specific to PU for next 12 months
Quality outcome measures specific to Nursing Professional Development for next 12 months

16. Quality outcomes (cont’d)
Sample Provider Unit Outcome Measures
Cost savings for customers
Cost savings for PU
# of participants in CE activities
# of CE activities
Staff/volunteer satisfaction
Learner satisfaction
Faculty satisfaction
Change in format of CE activities to meet learner needs
Change in operations to achieve strategic goals
Operational improvements
Quality/cost measures
Turnover/vacancy for PU staff/volunteers
Professional development opportunities for staff/volunteers

17. Quality outcomes (cont’d)
Sample Nursing Professional Development Goals and Outcomes
Professional practice behaviors
Leadership skills
Critical thinking skills
Nurse competency
High-quality care based on best-available evidence
Improvement in nursing practice
Improvement in patient outcomes
Improvement in nursing care delivery

18. Documentation overview
Self-Study and Activity Files
Submit by due date
Self-study is narrative response with supporting evidence/example for each criterion
Evidence/examples may be chosen from supplemental files submitted if desired, but not required
Activity files are chosen by AzNA
Representative of different types of activities (as applicable)
“live” activity
Enduring material activity
Web-based activity
Commercial support/sponsorship activity

19. Writing the narratives & examples
Narrative documentation with supporting evidence/examples
“Telling a story”
“Description of the wonderful work done by your organization for registered nurses”
Examples may be chosen from supplemental activity files but may also come from other activities or work done within the organization
“Describe” – tell the story
“Demonstrate” – provide evidence to substantiate the story

20. Sample review & Discussion
Handout (“Sample Responses”)

21. Tips for writing your response
Pause and reflect on the intent of the question
Answer the question directly
Do not add unnecessary extraneous information (do not “data dump”)
If an individual’s name is used in the narrative, indicate the position/title of the individual to ensure the reader can follow the response
Give enough background/context for the reader to understand the response
Ask several colleagues to read the responses and tell you if they make sense

22. HOW WRITTEN DOCUMENTATION IS EVALUATED
Threshold not met—organization is not ready to proceed forward; approval deferred to CE Coordinator; summary report provided to the organization regarding strengths and deficiencies
Additional documentation required—additional clarification is required to demonstrate adherence to accreditation criteria and determine whether threshold has been met
Threshold met—approval granted; final and letter sent to AzNA Approved Provider

23. Annual review requirements
Annual Approved Provider Continuing Education Summary Form
Annual activity documentation
Annual documentation requested by AzNA (progress reports, response to complaints, or similar)

24. QUESTIONS?